Identification Number:
HI 00825 TN 9
Intended Audience:See Transmittal Sheet
Originating Office:Systems OITPBS
Title:Inquiries and Referrals for HI/SMI
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 25 – Inquiries and Referrals for HI/SMI
Transmittal No. 9, 01/23/2020

Audience

PSC: BA, CS, ICDS, IES, ILPDS, IPDS, PETE, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, EIE, ERE, FCR, PETL;
OCO-ODO: BET, BTE, CCE, CTE TE, DEC, EHI, LCC, PAS, PETE, PETL, RECONR;

Originating Component

OITBS

Effective Date

Upon Receipt

Background

We reviewed and revised our instructions for establishing a premium payer for a uninsured enrollee. This transmittal does not introduce new policy.

 

Summary of Changes

HI 00825.080 Establishing a SMI Premium Payer for an Uninsured (T, M, J, or K) Enrollee

  • We made editorial changes for easy reading online.

  • We added instructions to clarify that SSA can not appoint a premium payer.

  • We removed section D and E

HI 00825.080 Establishing a SMI Premium Payer for Uninsured (T, M, J, or K) Enrollee

A. Establishing a third party premium payer

For an uninsured enrollee, who must pay medical insurance premiums by direct remittance, use a Third Party Premium Billing Request Form CMS-2384, to establish a mailing address for notices and premium billing statements sent by SSA and CMS, see HI 01005.810 .

  • The term "third party" in this instance is someone other than the claimant but not a State or formal group payee, see HI 01001.225.

  • A premium payer is not the same as a representative payee, therefore, do not use representative payee procedures in these instances.

CAUTION: SSA cannot appoint a premium payer employed by a health care facility. This includes hospital, medical institution, renal facility, social worker at a health care unit, etc. as detailed in HI 01001.240.

B. Form CMS-2384

Examine the form for completeness and legibility and handle as described in this section. Form CMS-2384 has three distinct parts.

  • Part I: Contains the claimant's authorization for premium billing notices to be mailed to the third party;

  • Part II: Contains the third party request to mail the billing notices to him or her; and

  • Part II: Contains the field office (FO) action. The FO completes all three parts of the form and forwards the form to the Program Service Center (PSC) of jurisdiction.

C. Enrolling T, M, J and K Claims

Instructions for processing the request:

Examine the MBR and or Medicare record to ascertain if the claimant is in a billable status (e.g., is in conditional payment status and no impediment to direct billing exist). If the claimant is in a billable status and the FO properly completed and approved Form CMS-2384 take the following actions:

  • process a POS change of address;

  • add a special message through the Miscellaneous Online Edited Transaction (MONET) System to the MBR indicating a claim specialist payee review will be conducted if benefit payments become payable (i.e. LAF C).

NOTE: If the POS action excepts through T2R, an Action Control Record (ACR) will generate in the PC of jurisdiction for manual input via MACADE.


HI 00825 TN 9 - Inquiries and Referrals for HI/SMI - 1/23/2020